Endoscopic and transcaruncular medial wall decompression in unilateral graves’ orbitopathy: a multicenter randomized study

Mahmoud A El-Samkary, Hesham A El-Sersy

The Egyptian Journal of Otolaryngology 2017 33(3):573-578

Background Thyroid eye disease is the most common orbital inflammatory disorder causing unilateral or bilateral proptosis in an adult. Infiltrative orbitopathy thyroid disease characterized by the deposition of immune complexes and inflammatory cells with subsequent fibrosis can severely affect vision and damage the optic nerve. In this study, we compare the safety and efficacy of transcaruncular versus endoscopic orbital decompression in the management of patients with unilateral Graves' orbitopathy. Patients and methods This is a retrospective comparative, center-based randomization which included 36 eyes of 36 different patients with Graves' orbitopathy and axial proptosis ranging between 20 and 26 mm. Complete ophthalmic examination included visual acuity, color vision, intraocular pressure, fundus examination and visual field assessment. Proptosis was measured by Hertel exophthalmometry and computed tomography orbit for all the cases preoperatively and 1.6 months postoperatively. There were follow-ups at day 1 postoperative, and at 1, 3, 6 months. All patients were photographed by the same camera. Patients were divided and were randomized on center based, distributed into two groups: the endoscopic group (18 eyes) were operated on through nasal endoscopic approach and the transcaruncular group (18 eyes) were operated on through the transcaruncular approach. Result There was significant reduction in proptosis in each group after surgery (P<0.001). The mean reduction of proptosis was more pronounced and statistically significant in the transcaruncular group (4.78±0.17 mm) as compared with the endoscopic group (3.61±0.18 mm) (P<0.001). The bony decompressed volume estimated by the serial computed tomography image was 0.75±0.23 cm3 in the transcaruncular group and 0.80±0.29 cm3 in the endoscopic group. There significant improvement in vision from 20/45 to 20/30 in both groups (P<0.001). Visual field defects have improved in 14 (77.8%) cases of the transcaruncular group, as compared with 15 (83.3%) cases of the endoscopic group with complete resolution of corneal staining in both groups within 1 month, postoperatively. Conclusion The transcaruncular technique showed better results because it has significantly better proptosis reduction, has 50% less residual proptosis, higher expanded compressed volume area and better improvement of visual acuity, although statistically nonsignificant.

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